Large Bone Flap Research Articles

Intracranial pressure changes in traumatic brain injury patients undergoing unilateral decompressive craniectomy with dural expansion

BackgroundThe aim of this study is to assess the ICP changes induced by a unilateral fronto-temporo-parietal DC with dural expansion after moderate to severe TBI. The effect of different bone flap sizes on ICP and the neurological outcomes were also evaluated after the decompressive surgery. Methods52 TBI patients with clinical and radiological evidences of increased ICP were included in this prospective study. All patients received unilateral fronto-temporo-parietal DC with dural expansion and ventriculostomy at contralateral Kocher's point. Postoperatively, ICP values and the largest antero-posterior (AP) diameter of bone flap removed was measured, and the clinical outcomes were assessed using Extended Glasgow Outcome Scale (GOS-E) at discharge and 6 months after DC. ResultsThe median ICP significantly decreased with an average of 56.7 % reduction from the initial opening ICP. Similar ICP changes were observed in all groups. This study also found that the large bone flap group (AP diameter >15 cm) demonstrated better postoperative ICP control as compared to the small bone flap group (AP diameter 12–15 cm), although not statistically significant. The SDH and cerebral swelling groups did better in the GOS-E at 6 months after TBI compared with cerebral contusion group. ConclusionThe ICP reduction in moderate to severe TBI patients undergoing unilateral fronto-temporo-parietal DC with dural expansion occurred in accordance with decompressive steps, regardless of intracranial lesions and the surgical procedure should be performed with the bone flap size of at least 12 cm in AP diameter for adequate and sustained ICP control.

Retracted: Investigation of the Effects of Large Bone Flap Craniotomy on Cerebral Hemodynamics, Intracranial Infection Rate, and Nerve Function in Patients with Severe Craniocerebral Trauma.

[This retracts the article DOI: 10.1155/2022/2681278.].

Analysis of Factors Affecting Good Neovascularization After Indirect Bypass Surgery: A Two-center Retrospective Study

The purpose of this study was to analyze factors affecting good neovascularization after indirect bypass surgery. From August 2000 to July 2020, postoperative image results and medical records of 132 patients (159 hemispheres) who underwent EDAS of indirect bypass surgery at two institutions were reviewed retrospectively. Based on DSA results, angiogenesis after indirect bypass was divided into "good" or "poor" according to the Matsushima criteria. STA flap length affecting GPN were analyzed in the entire group (n= 159) and a MMD group (n= 134). In the entire group, GPN after EDAS was observed in 94 (59.1%) hemispheres. Age, MMD, hypertension, and bone flap size were identified as significant factors in univariate analysis. Also, in the MMD group, 86 (64.2%) hemispheres showed GPN. Hypertension and bone flap size were significant factors in both univariate and multivariate analyses. Cutoff values of bone flap size and GPN were 47.91cm2 in the entire group and the MMD group. In all patients who received EDAS, good postoperative neovascularization was significant in those with a young age, MMD, without hypertension, and large bone flap size. No hypertension and large bone flap size were meaningful factors in the MMD group. AUROC showed that an appropriate bone flap size was 47.91cm2. However, a further controlled prospective study is needed.

The Effect Of Small Bone Window Craniotomy Removal on Lactic Acid and CRP in Patients with Hypertensive Intracerebral Hemorrhage in the Basal Ganglia.

Hypertensive intracerebral hemorrhage (HICH) seriously endangers the quality of life of patients and can even lead to death. Craniotomy is a common treatment method for HICH. The aim of this study was to investigate the efficacy of two different sizes of craniotomy in patients with HICH, as well as to evaluate their effects on C-reactive protein (CRP) and blood lactate levels. A total of 72 patients with HICH in the basal ganglia were operated on in our hospital from February 2017 to March 2019 and randomly divided into two groups: the small bone window (SBW) group (n = 37) and the large bone flap group (n = 35). The curative effects of the two kinds of operations were evaluated by the length of operation, the days of hospitalization, the rate of hematoma clearance, the rate of rebleeding, and the incidence of complications. Additionally, the levels of CRP and lactate were compared between the two groups. The results showed that the average intraoperative time, hospital stay, rebleeding rate, and postoperative complications of patients in the SBW group were less than those in the large bone flap group. Moreover, the number of patients in the SBW group with good postoperative recovery, including class V and class IV, was higher than that in the large bone flap group. Minimally invasive craniotomy with SBW reduced the lactic acid and CRP levels more quickly than the large bone flap group. An SBW was superior to a large bone flap in terms of the operative effect and lactate and CRP levels. It is concluded that an SBW has significant advantages over a large bone flap.

Observation of Clinical Application of Meningeal Patch Combined with Large Bone Flap Decompression in the Treatment of Craniocerebral Injury

Observation of Clinical Application of Meningeal Patch Combined with Large Bone Flap Decompression in the Treatment of Craniocerebral Injury

CRANIOTOMY WITH A HERMETIC CLOSURE OF THE CRANIAL CAVITY

Surgical intervention on the contents of the cranial cavity is universally carried out by applying several burr holes, which remain uncovered and serve as a site for the development of a number of postoperative complications. The lack of hemeticity of the skull in some cases require repeated intervention. The purpose of the proposal is to create a trepanation method that excludes the formation of burr holes and promotes hermetic closure of the cranial cavity, excluding the possibility of postoperative complications.The goal is achieved by sawing out conical holes in the skull with the simultaneous formation of small bone flaps in the form of a truncated cone. A large bone fragment of a derivative form is cut out with the proposed tool or in the usual way with a Gigli or Olivecrona saw. In the absence of contraindications, a large bone flap is placed in place, and small bone fragments are combined with the place of their sawing, thereby restoring the integrity of the skull, which is closed at the end of the intervention.The hermetic craniotomy method eliminates the possibility of developing postoperative complications inherent in craniotomy methods, carried out by applying burr holes.The method of craniotomy, which provides for hermetic closure of the cranial cavity, among other things, returns the brain to its natural state, protected from all kinds of external influences, including postoperative complications

Efficacy of Neuroendoscopic Treatment for Septated Chronic Subdural Hematoma.

Objective: Neuroendoscopic treatment is an alternative therapeutic strategy for the treatment of septate chronic subdural hematoma (sCSDH). However, the safety and efficacy of this strategy remain controversial. We compared the clinical outcomes of neuroendoscopic treatment with those of standard (large bone flap) craniotomy for sCSDH reported in our center. Furthermore, the safety and efficacy of the neuroendoscopic treatment procedure for sCSDH were evaluated.Methods: We retrospectively collected the clinical data of 43 patients (37 men and six women) with sCSDH who underwent either neuroendoscopic treatment or standard (large bone flap) craniotomy, such as sex, age, smoking, drinking, medical history, use of antiplatelet drugs, postoperative complications, sCSDH recurrence, length of hospital stay, and postoperative hospital stay. We recorded the surgical procedures and the neurological function recovery prior to surgery and 6 months following the surgical treatment.Results: The enrolled patients were categorized into neuroendoscopic treatment (n = 23) and standard (large bone flap) craniotomy (n = 20) groups. There were no differences in sex, age, smoking, drinking, medical history, antiplatelet drug use, postoperative complications, and sCSDH recurrence between the two groups (p > 0.05). However, the patients in neuroendoscopic treatment group had a shorter length of total hospital stay and postoperative hospital stay as compared with the standard craniotomy group (total hospital stay: 5.26 ± 1.89 vs. 8.15 ± 1.04 days, p < 0.001; postoperative hospital stay: 4.47 ± 1.95 vs. 7.96 ± 0.97 days, p < 0.001). The imaging and Modified Rankin Scale at the 6-month follow-up were satisfactory, and no sCSDH recurrence was reported in the two groups.Conclusions: The findings of this study indicate that neuroendoscopic treatment is safe and effective for sCSDH; it is minimally invasive and could be clinically utilized.

Investigation of the Effects of Large Bone Flap Craniotomy on Cerebral Hemodynamics, Intracranial Infection Rate, and Nerve Function in Patients with Severe Craniocerebral Trauma.

In order to explore the clinical value of large bone flap craniotomy, the effects of standard large bone flap craniotomy on cerebral hemodynamic indexes, incidence of postoperative intracranial infection, and neurological function in patients with severe craniocerebral trauma are investigated. 89 patients with severe craniocerebral trauma admitted from January 2020 to June 2021 are analyzed retrospectively. All patients are divided into a large craniotomy group (n = 45) and control group (n = 44) according to different surgical methods. The large craniotomy group is treated with large craniotomy decompression, and the control group is treated with traditional craniotomy decompression. The incidence of intracranial infection in each group is recorded, and NIHSS is applied to observe the neurological function recovery of 2 groups before and 1 month after operation. Besides, the patients are followed up after surgery and the Kaplan–Meier survival curve is obtained to compare the survival rate of patients in the two groups. It is clearly evident that the two surgical methods have certain clinical efficacy in the treatment of patients with severe craniocerebral trauma. Comparatively, the large craniotomy can further improve brain blood supply and improve neurological function recovery. Also, it can obtain low incidence of postoperative adverse reactions and intracranial infection.

Clinical Observation of Patients with Severe Craniocerebral Injury Treated by Step-controlled Decompression Combined with Large Bone Flap Surgery

Clinical Observation of Patients with Severe Craniocerebral Injury Treated by Step-controlled Decompression Combined with Large Bone Flap Surgery

Letter: Cranioplasty Reverses Dysfunction of the Solutes Distribution in the Brain Parenchyma After Decompressive Craniectomy

Letter: Cranioplasty Reverses Dysfunction of the Solutes Distribution in the Brain Parenchyma After Decompressive Craniectomy

Application and Mechanical Properties of Polyphenylene Sulfide-Based Composite Organic Materials in Skull Repair

For the problem that the metal titanium mesh has major shortcomings in clinical skull repair, poly(lactideglycolide acid) (PLGA) was dissolved in 1,4-dioxane and it was mixed with nano-scale powdery hydroxyapatite (HA) to obtain HA/PLGA. Nano-scale HA/PLGA/PPS composite materials were obtained by the physical blending method and direct composite method with polyphenylene sulfide (PPS). First, the material characterization of SEM and TEM was carried out during the preparation of the material. The nano-HA/PLGA/PPS composite material was implanted into the skull of patients with large bone flap decompression. The skull was repaired with isolated bone flaps and shaped nanomaterials. X-ray images, histopathological tests, and polymerase chain reaction (PCR) analysis of genes related to osteogenic activity were performed on the repaired damaged skull of the patients. After the operation, the skeleton formed by the prepared material was tested for mechanical indexes such as bending resistance and stretching. The results showed that the particle size of the material produced by direct composite was better, and HA/PLGA can be uniformly filled into the PPS. Nano-HA/PLGA/PPS composite materials can improve the proliferation ability of MG-63 cells and promote the osteogenic differentiation of the cells. After implantation of the material, the bone tissue healed well after the skull defect, and the mRNA expression of osteogenic related genes (ALP, Colα(I), IGF-1, OC, TGF-β1) was significantly increased. Post-operational bending strength and tensile strength tests of the implanted repaired skull skeleton show that compared with pure PPS, the addition of HA/PLGA material can increase the rigidity of the material.

Observation on the effect of craniotomy with large bone flaps on acute craniocerebral trauma and its influence on stress response of patients

Objective To investigate the effect of large bone flap craniotomy on acute craniocerebral trauma and its influence on stress response. Methods From January 2015 to December 2018, 80 patients with acute craniocerebral trauma were randomly divided into control group (40 cases) and observation group (40 cases) by random number table method.The patients in the control group were treated with conventional craniotomy and decompression, while the patients in the observation group were treated with craniotomy with large bone flaps.The changes of intracranial pressure, Glasgow coma index (GCS score), stress response index, prognosis and complications after 6 months were compared between the two groups before treatment and 2 weeks after treatment. Results Two weeks after treatment, the intracranial pressure in the observation group [(8.48±2.10)mmHg] was lower than that in the control group [(11.86±1.74) mmHg], while the GCS score[(10.35±1.87)points] was higher than that in the control group [(7.69±1.15)points](t=19.434, 7.663, all P<0.05). Two weeks after treatment, the serum levels of ACTH [(35.19±5.46)mg/L] and cortisol [(17.41±4.56)mg/L] in the observation group were lower than those in the control group [(48.91±4.95)mg/L and (28.93±7.48)mg/L] (t=11.774, 8.317, all P<0.05). Six months after treatment, the prognosis of the observation group(60.00%) was better than that of the control group (32.50%) (χ2=6.084, P<0.05). The incidence of complications of the observation group (5.00%) was lower than that of the control group (22.50%) (χ2=5.165, P<0.05). Conclusion Craniotomy with large bone flaps has good effect in the treatment of patients with acute craniocerebral trauma, and can reduce stress response and with fewer complications, which is worthy of clinical reference. Key words: Craniotomy; Decompression, surgical; Craniocerebral trauma; Intracranial pressure; Glasgow coma index; Stress response

CT Image Analysis of Large Bone Flap Craniotomy for Severe Traumatic Brain Injury

Objective: To explore the therapeutic effect of large traumatic craniotomy for severe craniocerebral injury and examine recovery using CT image analysis. Methods: 86 patients with severe craniocerebral injury admitted to our hospital were selected and divided into control group (n = 43) and observation group (n = 43). The observation group was treated with modified large traumatic craniotomy, while the control group was treated with standard large traumatic craniotomy. After the experiment, we analyzed the CT images before and after the operation, as well as the therapeutic effect, including the total effective rate of drugs, the incidence of complications, intracranial pressure, neurological deficit, language function score and motor function score, and analyzed their medical value. Results: The medical total effective rate, language function score and motor function score of the observation group were higher than those of the control group, and the incidence of complications, intracranial pressure and neurological deficits were lower than those of the control group, with statistical significance (P &lt; 0.05). CT images also showed that the patient condition was improved and recovery was good. Conclusion: Compared with standard craniotomy, the craniotomy with large bone flaps can achieve better therapeutic effect. The incidence of complications is reduced and the recovery is good. This type of procedure is beneficial to improve the prognosis and neurological function of patients.

Recurrence of Chronic Subdural Hematomas Requiring Reoperation: Could Small Trephination Be a Valid Alternative to Conventional Approaches?

Abstract Background: Chronic subdural hematomas (CSDHs) are one of the most common intracranial lesions treated in a neurosurgical department. They associate significant morbidity and mortality that increase in the case of recurrences requiring reoperation. Despite extensive published literature, there is still significant debate regarding optimal management of CSDHs and their potential recurrence. Objective: Identify factors for recurrence requiring reoperation of CSDHs in order to adjust our management strategies. Methods: A retrospective review of 64 cases harbouring 71 CSDHs that were surgically treated in the Neurosurgery Department of “Saint Pantelimon” Clinical Emergency Hospital over a period of two years (January 2016 - December 2017). Two main surgical techniques were used: small trephine and large bone flap craniotomy, according to the operating surgeon’s preference. CT scans were performed at admission and 24 hours postoperatively. Postoperative management was similar in all cases. Results: Recurrence requiring reoperation (RrR) was encountered in 16 (25%) of the reviewed cases. Reoperation was found to be significantly more often encountered in particular preoperative CT characteristics: laminar type (RrR=38,10%, p=0.027) and maximal thickness above 22 mm (43,75%, p = 0,013). Surgical technique had a substantial impact on recurrence: in trephinated cases, reoperation was required in only 8 of 51 patients (RrR=15,69%, p = 0.007), while large bone flap craniotomy associated a RrR of 61,54% (p = 0.008), which increased when associated with inner membranectomy (RrR=87,5%, p = 0,007) or subdural drain placement (88,89%, p = 0.007). Reoperations not only doubled the neurosurgical hospital length of stay, but also associated higher perioperative mortality rates (18.75% versus 14,58%). Conclusions: In our series, surgical technique had a decisive impact on the rate of recurrence. CSDH surgery is another example of “in medio stat virtus”, where finding the right balance between the least and most aggressive technique has the potential of providing the best outcomes, and thus small trephination could be taken into consideration.

Evaluation of Decompressive Craniectomy

Background and Purpose: Decompressive craniectomy is a surgery used to remove a large bone flap and opening the dura to allow edematous brain tissue to bulge extracranially. However, the efficacy of decompressive surgery to reduce the mortality and improve the outcome in patients with refractory intra-cranial pressure is still unclear. We investigated whether decompressive crani-ectomy is associated with improved conscious state and survival in patients with severely raised intracranial pressure and resistant to conservative management. Methods: We studied 20 patients with clinical and radiological evidence of increased intracranial pressure & indicated for decompressive crani-ectomy. All patients were followed postoperatively in ICU with serial follow up (CT). Consciousness level was evaluated using the Glasgow Coma Scale and Glasgow outcome score. Results: The overall mortality was 11 cases (55%), two cases remain in a vegetative state (10%), one case (5%) was severely disabled and six cases (30%) discharged with mild disability. Conclusion: In 20 cases with severely raised intracranial pressure resistant to conservative management Decompressive Craniectomy allowed (30 %) of cases to be discharged from hospitals with mild degree of disability for rehabilitation.

Reduction of Midline Shift Following Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction.

Background and PurposeHemicraniectomy is a decompressive surgery used to remove a large bone flap to allow edematous brain tissue to bulge extracranially. However, early indicators of the decompressive effects of hemicraniectomy are unclear. We investigated whether reduction of midline shift following hemicraniectomy is associated with improved consciousness and survival in patients with malignant middle cerebral artery infarctions.MethodsWe studied 70 patients with malignant middle cerebral artery infarctions (MMI) who underwent hemicraniectomies. Midline shift was measured preoperatively and postoperatively using computed tomography (CT). Consciousness level was evaluated using the Glasgow Coma Scale on postoperative day 1. Patient survival was assessed six months after stroke onset.ResultsThe median time interval between preoperative and postoperative CT was 8.3 hours (interquartile range, 6.1–10.2 hours). Reduction in midline shift was associated with higher postoperative Glasgow Coma Scale scores (P<0.05). Forty-three patients (61.4%) were alive at six months after the stroke. Patients with reductions in midline shifts following hemicraniectomy were more likely to be alive at six months post-stroke than those without (P<0.001). Reduction of midline shift was associated with lower mortality at six months after stroke, after adjusting for age, sex, National Institutes of Health Stroke Scale score, and preoperative midline shift (adjusted hazard ratio, 0.71; 95% confidence interval, 0.62–0.81; P<0.001).ConclusionsReduction in midline shift following hemicraniectomy was associated with improved consciousness and six-month survival in patients with MMI. Hence, it may be an early indicator of effective decompression following hemicraniectomy.

Symptomatic Epidural Fluid Collection Following Cranioplasty after Decompressive Craniectomy for Traumatic Brain Injury.

ObjectiveSymptomatic epidural fluid collection (EFC) arising as a complication of cranioplasty is underestimated and poorly described. The purpose of this study was to investigate the risk factors for development of symptomatic EFC after cranioplasty following traumatic brain injury (TBI).MethodsFrom January 2010 to December 2014, 82 cranioplasties following decompressive hemicraniectomy for TBI were performed by a single surgeon. Of these 82 patients, 17 were excluded from this study due to complications including postoperative hematoma, hydrocephalus, or infection. Sixty-five patients were divided into 2 groups based on whether they had developed symptomatic EFC: 13 patients required an evacuation operation due to symptomatic EFC after cranioplasty (Group I), and 52 obtained good outcome without development of symptomatic EFC (Group II). We compared the 2 groups to identify the risk factors for symptomatic EFC according to sex, age, initial diagnosis, timing of cranioplasty, cerebrospinal fluid (CSF) leakage during cranioplasty, size of bone flap, and bone material.ResultsA large bone flap and CSF leakage during cranioplasty were identified as the statistically significant risk factors (p<0.05) for development of symptomatic EFC. In Group I, 11 patients were treated successfully with 5 L catheter drainage, but 2 patients showed recurrent EFC, eventually necessitating bone flap removal.ConclusionA larger skull defect and intraoperative CSF leakage are proposed to be the significant risk factors for development of symptomatic EFC. Careful attention to avoid CSF leakage during cranioplasty is needed to minimize the occurrence of EFC, especially in cases featuring a large cranial defect.

Clinical effect of 58 patients with severe craniocerebral injury treated by surgery

Objective To investigate the clinical effect of standard large bone flap decompression for severe craniocerebral injury. Methods This study was performed in 58 patients with severe traumatic brain injury, according to different surgical methods, the patients were divided into control group and study group, 29 cases in each group.The control group was treated with conventional bone flap craniotomy, and the study group was treated with large bone flap decompression surgery.The clinical effect and complications were compared between the two groups. Results After operation, the patients were followed up for 5 months.The mortality of the study group (10.34%) was significantly lower than that of the control group (27.59%), and the difference was statistically significant (χ2=3.98, P<0.05). In addition, the good rate of the study group (55.17%) was significantly higher than that of the control group (27.59%), and the difference was significant (χ2=4.55, P<0.05). The preoperative intracranial pressure had no significant difference between the two groups.While at postoperative 1d, 3d and 5d, the intracranial pressure of the study group was significantly lower than that of the control group, and the difference was statistically significant (t=3.55, 4.02, 6.12, all P<0.05). The scores of GOS and BAI in the study group were significantly higher than those in the control group (t=5.02, 4.21, P<0.05). The incidence rates of complications such as cerebrospinal fluid leakage, trauma of cerebral infarction, trauma of epilepsy, hydrocephalus, wound infection of the study group were significantly lower than those of the control group, and the differences were statistically significant (χ2=4.00, 5.02, 456, 4.22, 3.99, all P<0.05). Conclusion Compared with conventional craniotomy, open standard big bone flap decompression can significantly reduce the mortality rate, decrease intracranial pressure, and improve the quality of life of patients, it has better curative effect and prognosis for patients with severe craniocerebral injury, and is worthy of clinical application. Key words: Decompression, surgical; Craniocerebral trauma

A Medical Insight on the of Biomaterials for Cranioplasty Surgery

Cranioplasty represent surgical repairs of defects or deformities of the skull which may come as a result of trauma or congenital malformations. The notable advance in cranioplasties came with the experimental groundwork in bone grafting, performed in the late 19th century, based on which, the use of autografts for cranioplasty became popular in the early 20th century. With the First and Second World Wars alternative metals and plastics were needed to cover large cranial defects suffered in combat as precious metals became scarce. As time passed metallic bone substitutes have gradually become obsolete and modern non-immunogenic plastics such as Polymethylmethacrylate (PMMA) snf Polyetheretherketone (PEEK) replaced them, the major downside of the technique being represented by the high costs. The authors present a statistic of 25 patients treated over a period of 4 years in 3 major neurosurgical units – which beneffited from the neurosurgical use of biomaterials for the repair of major cranial defects following congenital malformations, post-surgical cranial defects or trauma of the skull. We excluded large bone flaps for decompressive craniotomy. The authors used PMMA (Polymethylmethacrylate) and PEEK-based implants. There were 12 cases in which PMMA was used and 13 cases in which PEEK-based implants were used. The authors present a personal comparrison between the two materials. At the same time, the authors perform a comprehensive review of how the techniques have evolved from simple metal to modern biopolymers and how the modern technology will impact the future of cranial reconstruction

The Risk Factors for Hydrocephalus and Subdural Hygroma after Decompressive Craniectomy in Head Injured Patients.

ObjectiveThe present study aims to investigate 1) the risk factors for hydrocephalus and subdural hygroma (SDG) occurring after decompressive craniectomy (DC), and 2) the association between the type of SDG and hydrocephalus.MethodsWe retrospectively reviewed the clinical and radiological features of 92 patients who underwent DC procedures after severe head injuries. The risk factors for developing post-traumatic hydrocephalus (PTH) and SDG were analyzed. Types of SDGs were classified according to location and their relationship with hydrocephalus was investigated.ResultsUltimately, 26.09% (24/92) of these patients developed PTH. In the univariate analyses, hydrocephalus was statically associated with large bone flap diameter, large craniectomy area, bilateral craniectomy, intraventricular hemorrhage, contralateral or interhemisheric SDGs, and delayed cranioplasty. However, in the multivariate analysis, only large craniectomy area (adjusted OR=4.66; p=0.0239) and contralateral SDG (adjusted OR=6.62; p=0.0105) were significant independent risk factors for developing hydrocephalus after DC. The incidence of overall SDGs after DC was 55.43% (51/92). Subgroup analysis results were separated by SDG types. Statistically significant associations between hydrocephalus were found in multivariate analysis in the contralateral (adjusted OR=5.58; p=0.0074) and interhemispheric (adjusted OR=17.63; p=0.0113) types.ConclusionFor patients who are subjected to DC following severe head trauma, hydrocephalus is associated with a large craniectomy area and contralateral SDG. For SDGs after DC that occur on the interhemispherical or controlateral side of the craniectomy, careful follow-up monitoring for the potential progression into hydrocephalus is needed.